Article 4.3 - Long-Term Care Integration Pilot Program

California Welfare and Institutions Code — §§ 14139.05-14139.62

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Sections (31)

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The Legislature finds and declares that:

(a)Long-term care services in California include an uncoordinated array of categorical programs offering medical, social, and other support services that are funded and administered by a variety of federal, state, and local agencies and are replete with gaps, duplication, and little or no emphasis on the specific concerns of individual consumers.

(b)Although the need for a coordinated

continuum of long-term care services has long been apparent, numerous obstacles prevent its development, including inflexible and inconsistent funding sources, economic incentives that encourage the placement of consumers in the highest levels of care, lack of coordination between aging, health, and social service agencies at both state and local levels, and inflexible state and federal regulations.

(c)The office of the Legislative Analyst and others have pointed out that California’s systems of service delivery in a number of areas are dysfunctional, due to the fragmentation of responsibility and funding for interrelated services. Principles proposed by the Legislative Analyst to guide the restructuring of these systems include recognizing program linkages, coordinating service delivery mechanisms, removing barriers to innovation, and instilling financial incentives to promote prevention and coordination.

(d)It is both more efficient and more humane to restructure long-term care services so that duplicative and confusing eligibility criteria, assessments, intake forms, and service limitations will not inhibit consumer satisfaction, impede improvements in consumer health status, and result in the ineffective use of resources.

(e)There is a growing interest in community-directed systems of funding and organizing the broad array of health, support, and community living services needed by persons of all ages with disabilities.

(f)It is in the interest of those in need of long-term care services, and the state as a whole, to develop a long-term care system that provides dignity and maximum independence for the consumer, creates home and community based alternatives to unnecessary out-of-home placement, and is cost

effective.

§ 14139.1

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

(a)It is the intent of the Legislature to establish the Long-Term Care Integration Pilot Program that will integrate the financing and administration of long-term care services in up to five pilot project sites in the state. Contingent upon a state approved administrative action plan, at least one site shall be in a rural or underserved part of the state.

(b)It is further the intent of the Legislature to support, in each pilot project site, the development of a model

integrated service delivery system that meets the needs of all beneficiaries, both those who live in their own homes and those who are in out-of-home placements, in a humane, appropriate, and cost-effective manner.

§ 14139.11

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The goals of this pilot program shall be to:

(a)Provide a continuum of social and health services that foster independence and self-reliance, maintain individual dignity, and allow consumers of long-term care services to remain an integral part of their family and community life.

(b)If out-of-home placement is necessary, to ensure that it is at the appropriate level of care, and to prevent unnecessary utilization of acute care

hospitals.

(c)If family caregivers are involved in the long-term care of an individual, to support caregiving arrangements that maximize the family’s ongoing relationship with, and care for, that individual.

(d)Deliver long-term care services in the least restrictive environment appropriate for the consumer.

(e)Encourage as much self direction as possible by consumers, given their capability and interest, and involve them and their family members as partners in the development and implementation of the pilot project.

(f)Identify performance outcomes that will be used to evaluate the appropriateness and quality of the services provided, as well as the efficacy and cost effectiveness of each pilot project, including, but not limited to, the use of

acute and out-of-home care, consumer satisfaction, the health status of consumers, and the degree of independent living maintained among those served.

(g)Test a variety of models intended to serve different geographic areas, with differing populations and service availability.

(h)Achieve greater efficiencies through consolidated screening and reporting requirements.

(i)Allow each pilot project site to use existing funding sources in a manner that it determines will meet local need and that is cost-effective.

(j)Allow the pilot project sites to determine other services that may be necessary to meet the needs of eligible beneficiaries.

(k)Identify ways to expand funding options for the

pilot program to include medicare and other funding sources.

§ 14139.12

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

It is the intent of the Legislature that the costs of this pilot program to the General Fund will not exceed the direct and indirect costs that existing programs would expect to incur had the integrated services not been provided through this pilot program. If the Department of Finance determines, and informs the director in writing, that the implementation of this pilot program will result in any additional costs to the state relative to the provision of long-term care services to eligible beneficiaries, the department may terminate the operation of all or any

part of this pilot program. The state shall not be held liable for any additional costs incurred by a pilot project site. Any such determination made by the Department of Finance shall be available to any party upon request.

§ 14139.13

Amended by Stats. 2000, Ch. 857, Sec. 90. Effective January 1, 2001.

(a)Any contract entered into pursuant to this article may be renewed if the long-term care services agency continues to meet the requirements of this article and the contract. Failure to meet these requirements shall be cause for nonrenewal of the contract. The department may condition renewal on timely completion of a mutually agreed upon plan of corrections of any deficiencies.

(b)The department may terminate or decline to renew a contract in whole or in part when the

director determines that the action is necessary to protect the health of the beneficiaries or the funds appropriated to the Medi-Cal program. The administrative hearing requirements of Section 14123 do not apply to the nonrenewal or termination of a contract under this article.

(c)In order to achieve maximum cost savings the Legislature hereby determines that an expedited contract process for contracts under this article is necessary. Therefore, contracts under this article shall be exempt from Chapter 2 (commencing with Section 10290) of Part 2 of Division 2 of the Public Contract Code.

(d)The Director of the Department of Managed Health Care shall, at the director’s request, immediately grant an exemption from Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code for purposes of carrying out any contract entered into pursuant to this

article.

§ 14139.2

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The department shall serve as the lead agency for the administration of this chapter. The department’s responsibilities shall include, but are not limited to:

(a)Development of criteria for the selection of pilot project sites.

(b)Selection of the pilot project sites to participate in the pilot program.

(c)Providing, or arranging for, technical assistance to

participating sites.

(d)Development of specific performance outcome measures by which the program can be evaluated.

(e)Development of standards for complying with reporting requirements specified in state law for the programs integrated within the pilot program implemented pursuant to this article. The standards developed pursuant to this subdivision shall apply in lieu of any existing reporting obligations for the programs. The existing individual reporting requirements for programs integrated within the pilot program shall be deemed to have been met through the reports required by this section. Existing requirements for reports to the Office of Statewide Health Planning and Development shall not be eliminated.

(f)Seeking all federal waivers necessary for full implementation of the pilot program.

(g)Setting a payment rate consistent with Section 14139.5.

(h)Approval or disapproval of administrative action plans.

§ 14139.21

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The department may accept funding from federal agencies, foundations or other nongovernmental sources and may contract with qualified consultants to assist with the provision of technical assistance, the development of data collection, reporting, and analysis systems, or any other purposes that further the goals of this demonstration program. The department shall not accept funds from any entity that stands to gain financially from implementation of the pilot program. In contracting with consultants to assist with the pilot program, the department shall specify

timelines and delivery dates so as to ensure the continued implementation of the pilot program.

§ 14139.22

Amended by Stats. 2012, Ch. 438, Sec. 20. (AB 1468) Effective September 22, 2012.

(a)The department shall convene a working group that shall include the Director of Health Care Services, the Director of Social Services, and the Director of the California Department of Aging, or the program staff from each of those departments who have direct responsibility for the programs listed in subdivision (b) of Section 14139.32, and may include the Director of Rehabilitation, or program

staff from those departments with direct responsibilities for programs that may be included as a service in any pilot project site, and representatives from each pilot project site upon its selection.

(b)The department shall consult with the working group during the designing of the pilot program, in the selection of the pilot project sites, and in the monitoring of the program under this article, and shall utilize the working group as a resource for problem solving and a means of maintaining interdepartmental and intersite communication.

(c)The working group shall strive to ensure that the pilot program under this article makes maximum use of home-based and community-based services, and throughout the continuum of care for each beneficiary, encourages the use of the least restrictive environment in which the beneficiary can receive appropriate care.

§ 14139.23

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

Upon the implementation of the pilot program, responsibility for administering the programs integrated within the pilot program shall be transferred to the department, and shall be specified in an interagency agreement between participating departments. Prior requirements for any program integrated within this pilot program shall be deemed to have been met through compliance with the requirements established by this article, by the department for the pilot program by each county’s approved plan, and by the approved applicable federal waivers.

§ 14139.24

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The department shall seek all federal waivers necessary to allow for federal financial participation in the pilot program implemented pursuant to this article. This article shall not be implemented unless and until the director has executed a declaration that the approval of all necessary federal waivers has been obtained by the department.

§ 14139.25

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

Notwithstanding any other provision of this article, costs to the General Fund shall not exceed the amount that would have been expended in the absence of the pilot program.

§ 14139.3

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

(a)Pilot project sites may be comprised of a single county, a multicounty unit, or a subcounty unit.

(b)Each selected site shall do all of the following:

(1)Establish a consolidated long-term care services fund that shall accommodate state and federal fiscal and auditing requirements, shall be used solely for the purposes described in this article, and shall not be used for any county pooled investment

fund.

(2)Identify a local entity, that may be either a governmental entity or a not-for-profit private agency, to administer the fund. The local entity may be one that already exists, or may be established for the express purpose of administering the fund. This agency shall be designated as the long-term care services agency and shall contract with the department to carry out this article.

(3)Develop and provide to the department an administrative action plan that shall include, but is not limited to:

(A)A complete description of the covered scope of services and programs to be integrated.

(B)A complete description of the proposed long-term care delivery system and how it will improve system efficiency and enhance service quality.

(C)Demonstration of a willingness and commitment by the long-term care services agency to work with local community groups, providers, and consumers to obtain their input.

(D)Proposed measurable performance outcomes that the pilot program is designed to achieve.

(E)A description of the expected impact on current program services to Medi-Cal eligible beneficiaries and consumers of non-Medi-Cal services included in the integrated system.

(F)Assurance of minimal disruption to current recipients of long-term care services during the phase-in of the pilot project.

(G)Reasonable assurance that services provided will be responsive to the religious, cultural, and language needs of

beneficiaries.

(H)Assurances that providers who serve the needs of special populations such as religious and cultural groups or residents of multilevel facilities as defined in paragraph (9) of subdivision (d) of Section 15432 of the Government Code and community care retirement communities as defined in subdivision (u) of Section 1771 of the Health and Safety Code, will be able to continue to serve those persons when willing to contract under the same terms and conditions as similar providers.

(I)Specific alternative concepts, requirements, staffing patterns, or methods for providing services under the pilot project.

(J)A process to assure that Medi-Cal dollars are appropriately expended in accordance with federal requirements.

(K)A description of

how the pilot project site will maintain adequate fiscal control and ensure quality of care for beneficiaries.

(L)A description of how the pilot project site will coordinate, relate to, or integrate with Medi-Cal managed care plans, local managed care plans, and other organizations which provide services not part of the pilot project.

(M)A proposed timeline for planning and startup of the pilot project.

(N)An estimate of costs and savings.

(O)Demonstration of the financial viability of the plan.

(c)The administrative action plan shall reflect a planning process that includes long-term care consumers, their families, and organizations that represent them, organizations that provide

long-term care services, and representatives of employees who deliver direct long-term care services. The planning process may include, but is not limited to, the members of the local advisory committee required pursuant to Section 14139.31.

(d)The administrative action plan shall receive the approval of the county board of supervisors before it is submitted to the department for final state approval. The board of supervisors shall present evidence of the commitment to the administrative action plan of all publicly funded agencies that currently serve consumers who will be eligible under the pilot project, and all publicly and nonpublicly funded agencies that will be responsible for providing services under the pilot project. This evidence may include resolutions adopted by agency governing bodies, memoranda of understanding, or other agreements pertinent to the implementation of the plan.

§ 14139.31

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

In order to be selected, a pilot project site shall demonstrate that it has an active advisory committee that includes consumers of long-term care services, representatives of local organizations of persons with disabilities, seniors, representatives of local senior organizations, representatives of employees who deliver direct long-term care services, and representatives of organizations that provide long-term care services. At least one-half of the members of the advisory committee must be consumers of services provided under this chapter or their

representatives.

§ 14139.32

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

(a)The administrative action plan shall identify the funds to be transferred into the consolidated long-term care services fund.

(b)The funds shall include Medi-Cal long-term institutional care, the Medi-Cal Personal Care Services Program, and the In-Home Supportive Services Program and may include funds from the following programs and services:

(1)Multipurpose Seniors Services Program.

(2)Alzheimer’s Day Care Resources Centers Program.

(3)Linkages Program.

(4)Respite Program.

(5)Adult Day Health Care Program.

(6)Medi-Cal home health agency services.

(7)Medi-Cal home-based and community-based waiver programs.

(8)Medi-Cal hospice services.

(9)Medi-Cal acute care hospital services.

(10)Other Medi-Cal services, including, but not limited to, primary, ancillary, and acute care.

(c)Optional program funds enumerated in subdivision (b) of Section 14139.32 shall be included in the long-term care services fund in any case where a program was funded prior to its integration into the pilot project.

(d)In determining which project sites to select for participation in the pilot program, the department shall give preference to those sites that include funds from the largest number of programs existing within the project site at the time the site applies for selection, provided the administrative action plan meets all other selection criteria. With the exception of up to one rural county, preference shall be given to project sites that include primary, ancillary, and acute care in the consolidated fund, provided their administrative action plan meets all other selection criteria.

§ 14139.33

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The administrative action plan shall delineate the services to be provided to all eligible beneficiaries. At a minimum, services to be provided shall include all of the following:

(a)Care or case management, including assessment, development of a service plan in conjunction with the consumer and other appropriate parties, authorization and arrangement for purchase of services or linkages with other appropriate entities, service coordination activities, and followup to determine whether the

services received were appropriate and consistent with the service plan. Service coordination activities shall ensure that the records of each beneficiary are maintained in a consistent and complete manner and are accessible to the beneficiary or his or her family, and providers involved in his or her care. This shall be the case whether a beneficiary resides in his or her own home or in a licensed facility.

(b)Education of beneficiaries, their families, and others in their informal support network, including independent living skills training to maximize the independence of the beneficiary.

(c)In-home services.

(d)Adult day services.

(e)Institutional long-term care.

(f)Hospice

services.

(g)Linkages to acute care services and primary care services, if they are not included in the integrated plan.

§ 14139.34

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The administrative action plan may also include any of the following services:

(a)Transportation.

(b)Home modification.

(c)Medical services, including, but not limited to, primary, ancillary, and acute care.

(d)Housing and residential services.

(e)Other services determined by the pilot project to be necessary to meet the needs of eligible beneficiaries.

§ 14139.35

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The department may exempt a pilot project site from the requirements of subdivisions (d) and (f) of Section 14139.33 if both the following conditions are met:

(a)State funds were not being used in the geographic area covered by the pilot projects to provide those services at the time of application to the pilot program.

(b)The pilot project site can demonstrate to the department how it plans to develop these services, and within

what timeframe, during the pilot program.

§ 14139.36

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

(a)If primary, ancillary, and acute care are not included among the services offered by a pilot project site, the administrative action plan shall include all of the following:

(1)A mechanism for tracking the usage of these services by beneficiaries of the plan.

(2)Provisions for the future inclusion of those services in the integrated plan, including the process and timeline by which they will be

integrated.

(b)The department shall, in consultation with the pilot project sites, apply to the federal health care financing administration for a waiver that allows the pilot projects to include medicare funds in the long-term care services fund. Upon receipt of the waiver, within a time period to be designated by the department specific to each site, each pilot project site shall assume responsibility for primary, ancillary, and acute care services.

§ 14139.37

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

The administrative action plan shall delineate specifically how the pooled funds will be used to deliver services to all eligible recipients in the geographic area covered by the pilot project site.

§ 14139.38

Added by Stats. 1995, Ch. 875, Sec. 1. Effective January 1, 1996.

Participating counties shall continue their financial maintenance of effort for each of the programs integrated within the pilot program under this article. The amount of a county’s maintenance of effort shall be the same as if the program were not integrated within the pilot program pursuant to this article, and funds equal to this amount shall be deposited in the local consolidated long-term care services fund.

§ 14139.4

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§ 14139.41

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§ 14139.42

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§ 14139.43

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§ 14139.44

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§ 14139.5

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